Flexible annular stapler for closed surgery of hollow organs

ABSTRACT

A greatly improved flexible annular stapler for joining tubular organs is disclosed. The novel stapler features greater accuracy of operation and better control by the operator, as well as additional functions, such as internal illumination and viewing facility, and accomodation of a large number of accessories, such as fibroscopes and catheters. The novel stapler, moreover, features easy attachability of both stapling jaws and easy detachability of the head. The novel features are particularly useful for closed surgery. Also disclosed are novel methods and procedures for using a flexible annular stapler and the novel features disclosed herein--particularly under conditions of closed surgery.

FIELD AND BACKGROUND OF THE INVENTION

The present invention relates to excision of a section of a hollow ortubular soft organ, such as the digestive tube, and rejoining theremaining ends and, more particularly, to methods for performing theseoperations under conditions of closed surgery, using a flexible annularstapling and cutting instrument. The invention also relates to animproved construction of such an instrument.

Various ailments of the digestive tube, particularly of the esophagus,the stomach, the small intestines and the colon, such as tumors, chronicinflammation or other disorders, often require excision of a portion ofthe tube, followed by rejoining of the remaining end segments, throughanastomosis, to reestablish continuity of the tube. In some cases it isnecessary to thus join one organ to another; for example, the cut end ofthe small intestines may be joined to the colon, or the cut end of theduodenum may be joind to the stomach. In some other cases, two organs ortwo portions of the same organ may be joined side-to-side (rather thanend-to-end or end-to-side, as in the above cases). In the discussion tofollow and in the claims, the terms "parts of hollow organs" or just"parts" will be used, for brevity, to collectively denote the two partsto be joined, and the terms "part of a hollow organ" or just "part"--todenote each of the two parts to be joined, whether they are truly twodifferent hollow organs or two segments of the same hollow organ.

It has been common practice since the end of the '50s to use, for thepurpose of the anastomosis, a suitable annular stapling and cuttinginstrument. An example of such an instrument, to be referred toherebelow as stapler, is depicted in FIG. 1A. The stapler basicallyconsists of a tubular main body, at one end of which is an annularstaple gun, while the other end serves as a handle and has a knob andactivation levers thereon. A rod is slidably disposed inside the tubularbody, protruding through the staple gun and terminating with a roundhead that contains an annular anvil. The staple gun contains a set ofsurgical stapling pins, arranged in one or two concentric circles and acircular knife inside these circles. On the face of the anvil are shortgrooves, one opposite each staple pin, with arc-like depth profile.During surgery, this stapler is used, for example, to rejoin endsegments of the intestines after excision, by inserting it through alongitudinal cut in the side of the intestines and through the ends ofboth segments, then annularly folding and temporarily sewing one endover the face of the gun and one end over the anvil; the latteroperation forms the ends into partially closed flange-like butts.Subsequently, by turning the knob, the head with the anvil is pulledtoward the face of the gun, thus bringing the butts into mutual contact.Finally, by activating a lever on the handle, the staple pins are pushedthrough the flanges into the grooves in the anvil until they are benttight; at the same time, the circular knife cuts away the inner disks ofthe two adjoining flanges, leaving an annular ring as the joint.

This, conventional, type of stapler has several shortcomings:

It always requires an extra, longitudinal, cut; for multiple excisions,multiple extra cuts are needed.

It is not suitable for hard-to-reach or complicated portions of theintestiness, such as those inside the pelvis, nor for the duodenum;operation on the esophagus or the stomach is difficult.

It is suitable almost only for end-to-end joints.

The temporary sewing of the butt ends is difficult and the depth of theresulting flanges is small, thus risking leakage.

French patent FR 9204490 to the present applicant, which is incorporatedinto the present disclosure by reference, discloses a novel annularstapler that differs from the one described hereabove essentially in thefollowing (see FIG. 1B for an external view and FIG. 1C for alongitudinal-sectional view): The main, tubular, body consists of aflexible hose 26, which can be of any length and to one end of which ananvil assembly 18 is attached. Through hose 26 is slidably disposed aflexible cable 21, one end of which is pointed and to which a head 11 isattachable. The other end of cable 21 is attached to a handle 30 bymeans of a long screw 52, engaged by a nut 51, which is connected to aknob 46 so that turning the knob causes the cable to slide along thehose and thus--the head to move with respect to the anvil. The headcontains a cartridge with staple pins and a rigid hammer assembly 15 (tobe refrred to as hammer) that includes fingers, to push the pins, and acircular knife. Hammer 15 is connectable to the end of cable 21 by ascrew-like arrangement. Connected to the hammer through a spring is anannular base plate, which holds the cartridge of pins and has slots forpassage of the pins. Cable 21, which may be hollow, has a flat outersurface, which matches a flat in the shape of a central hole in anvil 18through which the cable slides; this is in order to keep the headangularly aligned with respect to the anvil prior to stapling. In handle30 there is a window 54, through which a millimeter scale 42, attachedto cable 21 is viewable, together with a fixed pointer. Operation ofthis stapler is similar to that of a conventional one, except that thestapling and cutting operation, after the two butts have made contact,is actuated automatically by continued turning of the knob (rather thanactivating a lever.

This novel stapler avoids the shortcomings of the conventional one,listed hereabove. In particular, it enables reaching any segment of thedigestive tube--either through a natural opening (mouth or anus) orthrough a single, conveniently located cut. It also enables end-to-sideor side-to-side joints.

Even so, the novel stapler of French patent FR 9204490 (to be referredto as the French patent) still has a few shortcomings and many as yetunrealized potentialities. One shortcoming is that in the disclosedconstruction there is an appreciable length of cable between the pointat which the cable emerges from the anvil and the point at which itenters the head structure, even when these two components are at theirclosest approach. This may allow some twist in the cable andconsequently some angular misalignment between the staple pins in thehead and the grooves in the face of the anvil, which may causemalfunctioning of the stapling action. Likewise, because of uneven backpull of an intestinal butt, the faces of the two components may not beparallel, or may not be axially aligned prior to the stapling action,which, again, could cause malfunction. Another shortcoming of theinstrument is in the operation of the handle; turning the knob may notbe the optimal way to activate the stapling and cutting operation. Yetanother shortcoming is the difficulty with which the head or anvil areare attachable or detachable, making such operations within the body, aswould be advantageous in certain procedures, close to impossible.

The unrealized potentialities are mainly associated with a new possiblemode of its employment, a mode that was not contemplated in the Frenchpatent but is the subject of the present invention, namely closedsurgery. The practice and techniques of closed surgery, such aslaparoscopy and thoracoscopy, have made tremendous progress over thepast five years and many surgical procedures on internal organs are nowcarried out in this mode. Whereas in conventional, open, surgery, arelatively large incision is made in the abdominal wall or chest, closedsurgery is characterized by insertion of very thin tools throughotherwise intact walls--usually with the aid of small tubular ports,called trocars, which also serve to seal the openings during operation.Some of these tools serve for viewing and usually include a video systemso that the entire operation is viewed and monitored on a video screen.The main advantages of closed surgery are (a) the much reduced trauma,resulting in fewer complications and much faster recuperation, which, inturn, shortens hospitalization and costs, (b) reduced risk of infectionand (c) considerable reduction of scars.

Closed surgery of the digestive tube is also being practiced. However,because the only practical instrument now available for anastomosis isthe rigid type described hereabove, which has to be operated under openconditions, the surgery ends up being, in part, of the open type (suchas laparoscopically assisted surgery) and thus foregoes some of theadvantages listed above. Basically, a flexible stapler, as describedhereabove and contrary to a conventional, rigid, stapler, lends itselfto completely closed surgery (such as laparospcopy and thoracoscopy),since the instrument is insertable either through the natural openingsor through a suitable opening in the intact wall and can reach almostany location. However, such use of a flexible stapler has not yet beenattempted nor, to the best of the inventor's knowledge, even beensuggested. Moreover, there are certain aspects of this type of surgerythat render direct utilization of the instrument, as disclosed in theFrench patent, difficult or impractical. For example, the preliminarycircular sewing of the butt ends over the instrument's head or anvil,difficult even during open surgery, is close to impossible. Undercertain circumstances it is preferable to place the active part of theinstrument in the affected area prior to excision; it is then difficultto sense its position within the intestines. Also, there is a need forendoscopy during the operation and it may be difficult to insert ormanipulate both the endoscope and the flexible stapler simultaneously inthe same tube. A similar difficulty holds for internal ultrasonicexamination.

Since, as stated, use of a flexible stapler in closed surgery has notyet been attempted and since, moreover, such an instrument is not yetavailable, there has been no clinical experience with anastomosis in thedigestive tube under conditions of closed surgery and certainly noexperience using such an instrument. Thus, no suitable procedures haveso far been developed, which fact keeps the clinicians and patients frombenefiting from the tremendous potential advantages of the technologyand also hinders potential acceptance by clinicians of the instrumentswhen they become available.

There is thus a recognized need for, and it would be highly advantageousto have, an improved stapler for anastomosis in the digestive tube thatwill overcome the shortcomings of presently known instruments and will,moreover, enable such operation under conditions of closed surgery.There is, furthermore, a need for practical methods and procedures forutilizing such an instrument under conditions of closed surgery.

SUMMARY OF THE INVENTION

The present invention successfully addresses the shortcomings of thepresently known configurations by providing an improved and morepractical flexible annular stapler, which is applicable to a widevariety of procedures and surgical conditions, including closed surgery.

More specifically, the stapler of the present invention enables accurateallignment of the head to the anvil during stapling, more convenientactivation of the stapling opration itself, possibility of introducinginto the stapler, or building into it, various auxiliary tools, such asimagers and catheters, and easy attachability and detachability of thehead and of the anvil, all of which are particularly advantageous foroperation under conditions of closed surgery.

The present invention discloses a novel construction of a flexibleannular stapler with a large number of optional features andattachments. It also discloses novel methods and procedures for using aflexible stapler, in general, and the improved stapler of the presentinvention in particular, for anastomosis of hollow organs, which methodscontribute to more efficient and cleaner operation.

According to the present invention there is provided a flexible annularsurgical stapler for stapling together two parts of hollow organs, thestapler comprising

(a) an elongated flexible tubular body;

(b) a handle attached to a first end of the body;

(c) a first jaw having an axial hole therethrough and two faces, a firstface being attached to the second end of the body;

(c) a flexible cable slidably disposed inside the body and through thehole, the cable consisting of two portions, a first portions defining anend segment, at least part of which protrudes from the second face ofthe first jaw; and

(d) a second jaw, defining a head, being attachable to the end segment;

the hole in the first jaw having a non-circular cross-sectional shapeand the end segment having a complementary cross-sectional shape such asto allow easy sliding of the end segment through the hole while keepingtheir mutual angular orientation about the axis of the hole fixed;

wherein one of the first and second jaws includes a hammer and the otherof the first and second jaws includes an anvil.

According to further features in preferred embodiments of the inventiondescribed below, the end segment of the cable is stiffer than the restof the cable and may be formed separately.

According to still further features in the described preferredembodiments, the handle includes

(i) a housing attached to the second end of the body,

(ii) an elongated externally threaded member disposed inside the housingand attached to the second portion of the cable,

(iii) a turning assembly, which includes an internally threaded memberthat engages the externally threaded member, and a knob outside thehousing, and

(iv) a lever assembly, which includes a manually pressable lever;

the turning assembly being operative, upon turning of the knob, to causethe cable to slide along the body; and the lever assembly beingoperative to keep the turning assembly at a fixed axial positionrelative to the housing, when the lever is not being pressed, and topull the turning assembly axially away from the body, when the lever isbeing pressed.

According to other features of the invention, the head is attachable tothe end segment, and the anvil is attachable to the body, by a snapcoupling.

According to yet other features of the invention, the cable has, overits entire length, a passageway therethrough for insertion of one ormore additional tools or parts thereof or to pass air or fluid to theend cap or to a balloon attached thereto.

According to another embodiment, the stapler further comprises anultrasonic transducer for ultrasonically probing tissue near the head,or an illuminator for illuminating tissue near the head, or imagingoptics for viewing tissue near the head, the imaging optics including acoherent fibers bundle disposed inside and along a passageway throughthe cable, or a video camera, for viewing tissue near the head.

Also according to the present invention there is provided a method forjoining two parts of hollow organs over an annular area defined on aplane in each of the two parts, whereby each part has an opening throughthe respective plane essentially inside the respective annular area, themethod sequentially comprising the steps of

(a) providing a flexible annular stapler having two round jaws;

(b) inserting the jaws into a first one of the two parts and advancingthe jaws to where one jaw is inside the first part and the other jaw isinside the second one of the two parts, each jaw being substantiallynear the respective plane;

(c) for each of the two parts, shrinking the opening so as to form an atleast partially closed butt that encloses the respective one of thejaws; and

(d) operating the annular stapler so as to pull the two the buttstogether and essentially combine the two annular areas into a combinedannular area, to staple the two organs or segments to each other overthe combined annular area and to cut away portions of the butts that arecentral to the combined annular area.

According to further features of the invention, steps (b) through (d)are carried out under conditions of closed surgery, inserting iseffected through a natural opening of the patient's body and shrinkingincludes, with respect to each of the two parts, pressing the tissuesurrounding the opening to form a pair of adjoining lips and staplingthe lips together by means of a linear stapler

An alternative method according to the invention, provides for joiningtwo parts of hollow organs over an annular area defined on a plane ineach of the two parts, under conditions of closed surgery performed on apatient, the method comprising the steps of

(a) providing a flexible annular stapler having a flexible body, tworound jaws and a flexible cable slidable through the body and through afirst one of the jaws and having an end protrudable from the first jaw,the first one of the jaws being attachable to the body and the secondone of the jaws being attachable to the end of the cable, both of thejaws being initially detached;

(b) inserting the flexible body through the patient's body wall;

(c) introducing the first jaw through the patient's body wall andattaching it to the flexible body;

(d) introducing the second jaw through the patient's body wall andattaching it to the end of the cable;

(e) having the first jaw inside the first one, and the second jaw insidethe second one, of the two parts of hollow organs and having each of thetwo parts form an at least partially closed butt at or near therespective plane, the butt enclosing the respective one of the jaws; and

(f) operating the annular stapler so as to pull the two butts together,to staple the two organs or segments to each other over an annular areaand to cut away portions of the butts that are central to the annulararea.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is an isometric drawing of an annular stapler of prior art.

FIG. 1B is an external side view of a flexible annular stapler of priorart.

FIG. 1C is a longitudinal sectional view of the stapler of FIG. 1B.

FIG. 2 is a longitudinal sectional view of the end portion of a stapleraccording to the present invention, showing the anvil, the head and theend segment of the flexible cable.

FIG. 3 is a longitudinal sectional view of the handle of a stapleraccording to one feature of the present invention.

FIG. 4A is a longitudinal sectional view of the head and the cable's endsegment of the stapler of the present invention, configured forillumination.

FIG. 4B is a longitudinal sectional view of the head of the stapler ofthe present invention with an alternative configuration forillumination.

FIG. 5A is a side view of the stapler of the present invention,configured with an optical fiber viewing system.

FIG. 5B is a longitudinal sectional view of the handle of a stapler ofthe present invention, showing a portion of the viewing system of FIG.5A.

FIG. 6 is a longitudinal sectional view of the stapler of the presentinvention, configured with a commercial fibroscope.

FIG. 7 is a longitudinal sectional view of the head and the cable's endsegment of the stapler of the present invention, configured with a videocamera.

FIG. 8 is a longitudinal sectional view of the head and the cable's endsegment of the stapler of the present invention, configured with anultrasonic transducer.

FIGS. 9A and 9B are a longitudinal sectional view and a cross sectionalview, respectively, of the head and the cable's end segment of thestapler of the present invention, featuring a snap coupling.

FIGS. 10A and 10C are a longitudinal sectional view and a crosssectional view, respectively, of the anvil and the end of the body ofthe stapler of the present invention, featuring a snap coupling.

FIG. 10B is an enlarged detail of FIG. 10A.

FIGS. 11 through 16 are sketches of a human colon, illustrating methodsaccording to the present invention of employing a flexible annularstapler in surgical procedures.

FIG. 17 is a sketch illustrating a method, according to the presentinvention, of closing butts of organs to be joined by a flexible annularstapler.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention is of methods and apparatus for performinganastomosis of the digestive tube under closed surgery conditions.Specifically, the present invention includes an improved flexibleannular stapler and can be used to conveniently and quickly perform suchanastomosis at any location and in conjunction with any of a largevariety of surgical procedures, which may include end-to-end,end-to-side and side-to-side joints.

The principles and operation of an improved annular stapler, as well asnew surgical methods utilizing it, according to the present inventionmay be better understood with reference to the drawings and theaccompanying description.

Referring now to the drawings, FIG. 2 illustrates the end portion of aflexible stapler similar to that of the French patent, but with animproved head-to-anvil alignment control. Flexible cable 21 is slidinglydisposed inside flexible hose-like body 26 along its entire length. Asegment 83 of the cable, a few centimeters long, at the end that isgenerally attachable to head 11 is designated as end segment. Accordingto a preferred embodiment of the invention, end segment 83, which slidesthrough hole 34 in anvil 18 when the head is relatively close to theanvil, is made to be substantially stiffer than the rest of the cable.According to an alternative preferred embodiment, the stiff end segment83 is a separately produced component, to be called extension rod, whichis attached to the end of cable 21.

According to the invention, there is also more freedom in choosing asuitable cross-sectional shape (rather than a circle with a flat, asspecified in the French patent) for the end segment, the cable and thehole, namely one that will optimize the stiffness of the end segment (orextension rod), with respect to both bending and twisting, as well asits rotational fixation within the similarly shaped hole in the anvil(and thus--of the head with respect to the anvil). The relativecross-sectional sizes of end segment 83 and hole 34, and thus the fitbetween them, should preferably be closely controlled, so as tomaximally fix their relative angular position, on the one hand, andallow easy sliding, on the other hand. Cable 21 itself preferably has anidentical shape, though its fit within the hole need not be as tight.Clearly, during operation, as the head is pulled toward the anvil, thestiff end segment slides through the matching hole in the anvil; theircooperation ensures that the opposing faces of the head and the anvilbecome essentially parallel and mutually aligned, both laterally androtationally, while approaching each other. Another advantage of a stiffend segment is that it lends itself better to forming a pointed end forpiercing tissue, as is required in certain procedures. It is noted thatthe stiff end segment (or extension rod) may be hollow, just as the restof the cable, to form a through passageway.

It is noted that the construction according to the French patent, whichserves as the preferred basis for the present invention, calls for ananvil to be part of the mechanical assembly that is attached to the endof the tubular body, while the mechanical assembly that is attached, orattachable, to the end of the cable (or the extension rod), which isreferred to as the head, contains, inter alia, a circular knife, ahammer and a cartridge of stapling pins. In the context of the presentinvention it is equally possible, and may sometimes be preferable, thatthe anvil be placed in the head and the hammer and stapling pins--in theassembly attached to the body. The knife, moreover, may be independentlyplaced in either one of the two assemblies. Therefore, for the sake ofboth brevity and generality, the two assemblies will sometimes, when nodifferentiation is necessary, be referred to as jaws. Whendifferentiation is necessary, the jaw attached to the end of the bodywill be referred to as anvil and the jaw attached to the end of thecable will be refrred to as the head. The use of the term anvil is basedon the examplary configuration for convenience only, with the otherconfiguration (i.e., anvil in the head and hammer and pins in the jawattached to the body) being understood to also come within the scope ofthe present invention. Sometimes the term anvil is used to denote thepart itself (rather than the jaw), in which case the meaning will beunderstood from the context.

FIG. 3 illustrates an improved handle portion of the flexible stapleraccording to the present invention. As before, the end of flexible cable21 is connected to a long screw 52, which is engaged by a nut 51 that isrotationally activated by a manual knob 46. However, knob 46, ratherthan being axially held by an annular tongue-and-groove arrangement atthe end of handle housing 47, is now held by a similar tongue-and-groovearrangement in a separate plate 102 that is attached to a lever 104,which is loaded by spring 106. Spring 106 acts to normally keep plate102 adjacent to, and touching, end 47 of the handle housing; the axialmovement of the cable inside the body is then controlled by turning knob46, as before. When lever 104 is pressed, though, the knob is pushedaway from the handle, pulling the entire cable assembly with it. Thisfeature would normally be utilized as follows: At the beginning ofoperation the knob is turned counterclockwise until the head and anvilare the desired distance apart. After attaching the butt ends of thetubular organ being operated on to the jaws, the knob is turnedclockwise, causing the two butts to approach each other. The surgeonwatches millimeter scale 42 (FIG. 1B) attached to the cable andviewable, together with a fixed pointer, through window 54 in thehandle. When the position of the scale indicates that the two butt endshave made contact, the surgeon pushes lever 104 and thus causes thecable to be pulled further and to thus activate the stapling and cuttingmechanism. Alternatively, there may be a stopper attached to screw 52 atthe end of the cable inside the handle, such that will impinge on theend of nut 51 when the two butts have made contact and thus prevent anyfurther travel due to turning of the knob. The advantage of this featureis that it provides the surgeon with tactile sense, and thus bettercontrol, of the stapling operation.

Referring now to FIG. 4A, which illustrates the head portion of apreferred embodiment of a flexible stapler with an internal illuminator,there is shown a stapler basically similar to the one disclosed in theFrench patent, the essential differences being as follows: There is ahollow passageway along the entire flexible cable 21 and its end segment83. Through this passageway there is disposed an optical fiber 62, or abundle of fibers. The end of this fiber that is in the handle (notshown) is optically coupled to a fiber illuminator; the fiberilluminator and the method of coupling it to the fiber may be any of anumber known in the art. The fiber illuminator may be attached to thehandle or it may be in a stationary console, with the fiber extending toit from the end of the handle. The other end of fiber 62, whichprotrudes from end segment 83 of the cable, is optically coupled to adiffuser 64, or a similar optical element, inside cap 25 of the head ofthe stapler. Cap 25, which forms the end of the head farthest from thecable and will therefore be referred to as the end cap, and whichusually has a conical or hemispheric shape, is here made of an opticallytranslucent or transparent material, such as polymers used for spectaclelenses. Operation of the instrument is similar to that of its previousversion, except that when the illuminator is activated, light emanatesfrom the cap of the head to illuminate the surrounding tissue and isusually visible through the wall of the digestive tube (either directly,as in open surgery, or through the laparoscope or thoracoscope) and thusthe location of the head with respect to the digestive tube isindicated.

It is noted that an optional passageway along the instrument is alsoshown in the French patent, where it, however, serves to supply air to adilatation balloon at the tip of the head. The passageway according tothe present invention must accommodate the optical fiber and mayoptionally serve for both the fiber and the air supply. According to analternative embodiment, the optical fiber is replaced by a pair ofwires, which are connected inside the head to a lamp and at the handleend--to a voltage source. In another alternative embodiment, shown inFIG. 4B, end cap 25 contains both a lamp 66 and a small battery 68; inthis case there are no wires through the cable and thus no need for apassageway solely for the purpose of illumination; this alternative ismost suitable for a disposable instrument. It is appreciated that thestapler shown in FIGS. 4 is by way of example and that a flexiblestapler of any construction can be modified to incorporate an internalilluminator according to the present invention.

Another possible configuration is shown in FIG. 5A, which depicts apreferred embodiment of a flexible stapler with internal imagingfacility. This is an augmented version of the configuration describedhereabove in conjunction with FIG. 4A, whereby there is disposed throughthe passageway a coherent bundle of optical fibers 70. The end of thebundle of fibers protrudes through a hole in the end cap of the head,where an objective lens assembly 72, of any suitable design known in theart, serves to project an image of the surrounding inner wall of theintestines onto the near end of fiber bundle 70. Preferably atransparent balloon is stretched over end cap 25 (including theobjective lens assembly) and inflated by air through the passageway;this aids in dilating the inner surface of the intestines and protectsthe surface of the lens. An illuminator 76 projects light into anillumination fiber 78, which runs through the passageway alongside fiberbundle 70 and whose other end also protrudes through the end cap, toilluminate the viewed area; it is appreciated, however, that othermethods of illumination, as, for example, a separately insertedillumination fiber, may be employed. The other end of the fiber bundle,namely that which protrudes from the cable in the handle is terminatedin a viewing assembly 82, which includes a video camera (not shown), forviewing the image on a video screen 81, and/or in an optical eyepiece80, for direct viewing. The viewing assembly may be any of a number ofcommercially available models. In a disposable stapler the viewingassembly, including a lens 86 (FIG. 5B) for coupling it to the end ofthe fiber bundle, is reusable, whereas the fiber bundle and the opticsin the head are disposable with the stapler. In this case the viewingassembly must be conveniently attachable to the end of the fiber bundle.One preferred way of doing this, depicted in the cross-sectional view ofthe handle in FIG. 5B, is to mount coupling lens 86 of viewing assembly82 in a tube 84 that is externally threaded (like a screw) with a pitchidentical to that of screw 52 at the end of cable 21; this tube isscrewed into nut 51, which also engages screw 52 and is coaxiallyattached to the turning knob 46, so that the coupling lens is focused onan end 88 of fiber bundle 70 (which protrudes from the end of screw 52,which is hollow). Thus, when knob 46 is turned, to move cable 21relative to body 26, viewing assembly 82 moves at the same rate, keepingit at a constant distance from end 88 of the fiber (which moves with thecable).

According to an alternative embodiment of the fiber-based imager, thefibers bundle terminates with an objective lens inside thehead--similarly to the depiction in FIG. 4A. Clearly, in this case endcap 25 of the head should be transparent and made of optical-qualitymaterial, such as polymers used for spectacle lenses.

Another alternative embodiment of a flexible stapler with an internalfiber-based imager is shown in FIG. 6: There is provided a passagewaythrough the entire instrument of sufficient diameter to allow threadingthrough it a suitable commercially available fibroscope 90. Such afibroscope is available, for example, from the Ova-Med Corporation inSunnyvale, Calif. and usually includes an illuminator 76, an eyepiece 80and a video screen 81. The tip 92 of the fibroscope can either protrudethrough a hole in end cap 25, as shown in the drawing, or be positionedinside a transparent cap, as in FIG. 4A. The advantage of thisembodiment, over the previous one, is that it can easily be deployed orremoved at will, thus saving its cost when not needed, especially whenthe stapler is disposable. It is appreciated that the same arrangement,that is a clear passageway through the entire instrument, including thecable and all its parts and possibly the end cap, can be utilized for avariety of thinly formed or catheter-like tools. Such tools may bespecially made for the purpose or may be tools originally intended forother applications, such as laparoscopy, hysteroscopy, angioscopy,bronchospcopy, sinusoscopy, choledoscopy, etc.; they may include (besidea fibroscope or microendoscope), for example, an illuminator, a videocamera, an ultrasonic probe, a suction device, a scraper, a surgicaltool, an irrigator, a guide wire, etc.

Another configuration of a flexible stapler with an internal imagingfacility is shown in FIG. 7. There is mounted inside cap 25 of the heada miniature video camera 94, consisting of an objective lens assembly 96and an array of photoelectric devices 98, which is connected to anelectronic drive circuit (not shown). The latter is connected to anelectric cable 93 that runs through a passageway along the entireinstrument and terminates at an electronic video assembly, whichdisplays the image on a video screen. The miniature video camera and theexternal video assembly are commercially available. Illumination for thecamera is, again, preferably provided by an illuminator as describedhereabove, or by any other method. The lens 96 can alternatively beplaced inside the cap, which is made transparent (similarly to FIG. 4A).If the stapler is to be disposable, the assembly of end cap and camera(which is too expensive to be disposable) is made to be easilyattachable to the head.

Yet another configuration of the flexible stapler according to thepresent invention, which allows internal ultrasonic examination, isshown in FIG. 8. An ultrasonic transducer array 91 is mounted on end cap25, preferably protruding therefrom, and connected by electric wiringthrough a passageway along the instrument to an external drive--andcontrol console (not shown). An inflatable balloon 74 is stretched overthe cap. Water, or another suitable fluid, is injected into thepassageway, for example, by means of a syringe fitting into a hole inthe center of knob 46 (FIG. 1B), and is made to inflate the balloon,through a hole in the end cap, until it makes good contact with theinner wall of the digestive tube. Alternatively, the fluid is suppliedto the balloon through a catheter that is threaded through thepassageway and protrudes through the hole in the cap. The ultrasonicarray is then operated by means of the console in the usual manner.

A novel configuration for attaching the head to the end of the flexiblecable (alternative to the previously disclosed set screw arrangement) isa snap coupling, that is--an arrangement by which the head may be simplypushed onto the end of the cable until a flexible, or spring-loaded,member on the head engages a feature, such as a notch, on the cable andwhereby the two parts thereafter remain interlocked until intentionallyreleased. This feature is useful in certain procedures in that itenables easily attaching the head to the cable inside the patient'sbody, possibly inside the affected organ, and is particularlyadvantageous for closed surgery, as will be illustrated herebelow. Thereare many ways known in the art to realize this configuration. Oneembodiment, presented here by way of example, is depicted in FIG. 9A,which shows a partial longitudinal-sectional view of the head, and FIG.9B, which shows a cross-sectional view at the plane marked H--H in FIG.9A. In this example, the head includes the hammer 15, which is connectedto the shell 23 by tension spring 132. The end 22 of the cable isattachable to the hammer as follows: The top plate of the hammer 15 hasaround its center a ring-shaped protrusion 140, with a central hole thatis a continuation of the hole through the top plate of the hammer andhas therefore the identical size and shape. In the surface of that holeis a circular notch 141, which accomodates two arculate members 142. Thearculate members 142, more clearly seen in FIG. 9B, are disposedsymmetrically within notch 141 and each pressed inward by a compressivespring 133, the travel being stopped by two protrusions 134 and 135within the notch. The end segment 22 of the cable has a notch 143 cutaround it somewhat below its pointed tip, which notch accomodates anyprotruding portion of the arculate members 142. The inner surfaces ofthe arculate members 142 are bevelled so that when the members are atthe stopped position, the arculate top and bottom edges of the bevelledinner surface are part of circles that are, respectively, somewhatsmaller, and just greater, than the maximal diameter of the end segmentof the cable between its tip and the notch 143 (which, preferably issomewhat smaller than the diameter of the rest of the end segment).Operation of this mechanism is as follows: The cable is initiallydetached from the head. When the end segment of the cable is pushed intothe hole through the hammer, its pointed tip pushes on the bevelledinner surface of the arculate members, causing them to be pushed outwardenough to allow the cable segment to slide in. When the notch in thecable segment reaches the arculate members, the latter snap back totheir stopped state, engaging the notch and thus locking the cablesegment to the hammer.

In order to unlock and release the cable from the head, there isprovided, in the exemplary embodiment shown and as depicted in thecross-sectional view in FIG. 9B, a release mechanism as follows: Theends of arculate members 142 which touch the protrusions 134 and 135 areshaped to form funnels stradling the protrusions. One protrusion, 134,is fixed, while the other protrusion, 135, is movable and connected to arod 136, which protrudes through the end cap 25 and ends with a button137. A compressive spring 138 keeps the rod 136 and the protrusion 135normally retracted. In order to unlock the snap mechanism, the button137 is pushed, which cause the funnel-forming ends of arculate members142 to be wedged by the two protrusions, thus pushing the arculatemembers apart--enough for the cable segment to be able to slide through.When the head is then pulled away from the cable, it is released.According to an alternative version of this embodiment, part of the rod136 is made of soft iron and the rod is surrounded by an electromagneticcoil (disposed internally to the spring 138), so that when an electriccurrent flows through the coil, it exerts a magnetic force on the rod inan inward direction. The coil is connected to an external switch andcurrent source by a pair of conductors (not shown); each conductorconsists of a pair of contact pads, one pad being on the end segment 22of the cable and connected to a wire running through the cable and theother pad flexibly mounted on the hammer's protrusion 140 and connectedby wire to the coil. To unlock the mechanism, the switch (located on anexternal console or on the handle) is simply closed. It is appreciatedthat even in the first version, the force needed on the button to effectunlocking action is small enough to be practically applicable inside thebody under closed surgery.

A snap coupling configuration is also possible for the attachment of theanvil to the body. This feature as well is useful in certain procedures,in that it enables easily attaching the anvil to the body of the staplerinside the patient's body, possibly inside the affected organ, and isparticularly advantageous for closed surgery, as will be illustratedherebelow. Again, many ways are known in the art for realizing thisconfiguration. One possible embodiment, presented by way of example andillustrated in FIGS. 10A-10C, is similar to that described hereabove forattaching the head to the cable, though somewhat simpler, since there isno operative need to unlock inside the body.

The end of the body is attachable to the anvil as follows: Asillustrated in FIG. 10A, which shows a longitudinal section, and FIG.10B, which shows details of FIG. 10A, the bottom of the anvil 15 hasaround its center a ring-shaped protrusion 120, with a central hole thataccomodates the cylindrically shaped end of the body 26. In the surfaceof that hole is a circular notch 121, which contains an open ring-shapedspring disc 122. The spring disc 122 is more clearly seen in FIG. 10C,showing a detailed cross sectional view of the protrusion area, at theline marked A--A in FIG. 10A. The inner surface of the spring disc 122is bevelled so that when the disc is unflexed, its minimum innerdiameter (near the disc's left surface) is somewhat smaller, and itsmaximum inner diameter (near the disc's right surface) just greater,than the diameter of the end segment of the body 26. The end segment ofthe body has a notch 123 cut around it, which notch accomodates anyprotruding portion of the spring disc 122. Operation of this mechanismis as follows: The body is initially detached from the anvil. When theend segment of the body is pushed into the hole at the anvil'sprotrusion 120, it pushes on the bevelled inner surface of the springdisk, causing it to be widened enough to allow the body segment to slidein. When the notch in the body segment reaches the spring disc, thelatter snaps back to its unflexed state, engaging the notch and thuslocking the body to the anvil.

In order to unlock and release the body from the anvil, there isprovided, in the embodiment shown and as depicted in the cross-sectionalview in FIG. 10C, a wedge 124. The wedge is disposed opposite theopening in the spring disc 122 and is held within a hole through thering 120, protruding therefrom. In order to unlock the snap mechanism,the wedge 124 is pushed, which causes it to press against the open endsof the spring disc and thus to widen it enough for the end of the bodyto be able to slide through. When the anvil is then pulled away from thebody, it is released.

FIG. 17 illustrates schematically and by way of an example an improvedmethod for generally preparing for, and performing, anastomosis of thedigestive tube when utilizing a flexible stapler, such as disclosedherein or in the French patent. The present example concerns excision ofa section of the colon. At the stage of the procedure shown, theaffected part of the colon has been excised, leaving two open butts ofthe colon, and the stapler has been inserted so that its head 11 is justinside one butt and its anvil 18 is just inside the other butt, withflexible cable 21 connecting the two. The end of each butt is now pulledover the respective jaw and pressed together to form two linealadjoining lips 110. The two lips are stapled together, by means of anylinear stapler 112 used in the practice of open- or closed surgery, asthe case may be. Such staplers are available, for example, from the U.S.Surgical Corporation. It is noted that the flexible cable, owing to itsthinness, does not materially interfere with this stapling operation andallows the joining of the lips around itself. Subsequently the annularstapler is activated in the usual manner, whereby the two butt ends arepulled together, forming adjoining flanges, which are then stapledtogether annularly while their central discs are cut away. It is notedthat the annular knife in the head of the stapler is generally hardenough to cut through staple pins left by the linear stapler. It is alsonoted that this method of preparing the butt ends for anastomosis ismuch easier and faster than the conventional method of hand sewing andthat it is therefore particularly suitable for closed surgery. It isappreciated, however, that the method can also be advantageously used inopen surgery.

It is noted that the improvements in flexible staplers and the methodsutilizing them, described hereabove are applicable in any form ofsurgery of the digestive tube but are particularly advantageous inclosed surgery. However, the very use of a flexible annular stapler inperforming anastomosis of the digestive tube under closed surgery ingeneral is considered to be part of the present invention. The mainadvantage of such use is that the flexible stapler is insertable throughthe mouth or the anus or possibly also through a suitable trocar in theabdominal wall, to reach almost any location, thus eliminating the needfor a wide incision through the wall--which is required for utilizing aconventional stapler. The other alternative--manual suturing orstapling--is much more difficult, particularly in closed surgery, andtakes longer. Moreover, for some hard to reach locations such incisionsare not possible and manual stitching is even more difficult, so that aflexible stapler is the only practical alternative. Further advantagesof using a flexible stapler in general, or an improved one according tothe present invention, in closed surgery of the digestive tube may beevident from the description of methods disclosed herebelow by way ofexamples.

FIG. 11 illustrates schematically, by way of an example, the usage of aflexible stapler in a typical closed surgery of the digestive tube,which in this case aims at excision of a malignant section of the colon.First, the colon (160) is cut across below and above the malignancy(161) and the extirpated sement (162 dwg. `A`) is placed in a bag, whichhas been introduced, and is subsequently removed, through an abdominalincision (as shown in `E`) or through the distal portion of the colon.At the next step, marked in the illustration as `A`, a thread isstitched like a purse-string around the end of each remaining segment(163 and 164). At the next step, the flexible stapler, with its headpulled close to its anvil, is pushed through the anus until the headprotrudes from the lower segment; then the knob on the handle is turneduntil the head is sufficiently distant from the anvil, whereupon head 11(dwg. `B`) is inserted into the upper segment (163), while keeping anvil18 inside the lower segment (164). At the next step, which reaches thestate illustrated in `B`, the thread at the end of each remainingsegment is pulled, thus creating a flange of colon tissue closing on theanvil or the head. It is noted that the latter two steps can beadvantageously replaced by the linear stapling method describedhereabove. In the last step, illustrated in `C`, the knob is activatedto pull the head and anvil together--to complete the anastomosis;subsequently the stapler is pulled back through the anus, leaving a welljoined colon, as shown in `D`.

It is noted that the last discussed example, as well as further examplesto be discussed herebelow, concern end-to-end anastomosis. It isappreciated, though, that procedures can be similarly developed forend-to-side and side-to-side anastomoses.

FIG. 12 illustrate schematically an improved procedure for excising amalignant segment of a digestive tube, utilizing a flexible stapler;again, the example of a colon is used. First, the colon is sutured or,preferably, linearly stapled shut below the malignancy, then a cut ismade across, just below the suture and the proximal, sutured butt(containing the malignancy) is bent away. Next the flexible stapler,with its head pulled close to its anvil, is pushed through the anusuntil the head protrudes from the (open) end of the distal segment; thenthe knob on the handle is turned until the head is sufficiently distantfrom the anvil. At this point the situation is as depicted in `A`. Next,the end of the distal segment is sutured or, preferably, linearlystapled, to close on the anvil, and a lateral cut is made in theproximal segment of the colon above the malignancy, as depicted in `B`.Then the head of the stapler is inserted into the upper colon throughthe lateral cut, as shown in `C`. Next, the colon is sutured or,preferably, linearly stapled, to close on the head; it preferably isalso sutured or linearly stapled shut just below the lateral cut; thenthe malignant segment is cut away from the sutured proximal butt, asshown in `D`. Completing the lateral cut in that segment enablesremoving it from the cable, as in `E`. Finally the handle is activatedto pull the two butts together, as shown in `F`, and to then carry outstapling and cutting, as described hereabove. After pulling the staplerback out through the anus, the colon remains joined and clear, as shownin `G`. It is noted that this method minimizes the time that the colonis open, thus minimizing possibility of soilage, which may beparticularly bothersome under closed surgery, e.g. because of the morelimited sponging ability. It is also noted that the method of linearstapling, described hereabove, is particularly convenient for theintermediate suturing-or stapling operations called for in the presentprocedure.

FIG. 13 illustrate schematically a further improved procedure forexcising a malignant segment of a digestive tube, utilizing a flexiblestapler; again, the example of a colon is used. This procedure utilizesa flexible stapler with an attachable head as described hereabove. Itprovides even cleaner preparation for anastomosis than does thepreviously described procedure and is therefore even more advantageousto closed surgery. According to this procedure, the colon is firstsutured or stapled shut at two adjacent cross planes below the malignantsegment, then cut across between the two planes, as shown in `A`, andthe proximal butt is bent away. Next, the body of the stapler, with onlythe anvil attached, is inserted through the anus and pushed until theanvil reaches the sutured lower, distal butt; the progress of the anvilthrough the colon may be aided by threading a balloon, attached to acatheter, through the passageway along the instrument, disclosedhereabove, while the cable is kept maximally retracted, to just protrudefrom the anvil, and inflating the ballon. . Then the knob is turned toextend the flexible cable out of the anvil; its pointed end easilypierces this butt and protrudes therefrom, as illustrated in `B`. Nowthe head is inserted through a suitable small incision in the abdominalwall, as, again, shown in `B`, and attached to the end of the cable; thesnap-on feature described hereabove is particularly advantageous forsuch attachment. Subsequently, a lateral cut is made above the malignantsegment and the situation is then as depicted in `C`, which is identicalto that of FIG. 12B, so that the procedure continues as in thepreviously described procedure. It is again noted that the method oflinear stapling, described hereabove, is particularly convenient for theintermediate suturing- or stapling operations.

Another procedure utilizing a flexible stapler, which features evengreater cleanliness and maximum simplicity, is illustrated schematicallyin FIG. 14--again, by way of an example of excision in the colon. Thisprocedure is suitable for cases where the affected segment is relativelyclear, such as benign small tumors or inflammation. According to thisprocedure, the flexible stapler, with the head drawn close to the anvil,is first pushed through the anus until the head just reaches theaffected segment; the knob is then turned to extend the head until itclears the affected segment; it is noted that the internal illuminationattachment, disclosed in the present invention, is advantageous inlocating the head with respect to the segment. Next, the colon issutured or stapled just below the head and just above the anvil, toenclose them, and a cut is made across each end of the affected segment,next to the sutures, as depicted in `A`; it is noted that here again themethod of linear stapling is particularly convenient. Then, according tothe preferred procedure, the affected segment, which is now loose butstill enclosing the cable, is pushed to touch the cable, as shown in`B`. Next, the segment is sutured or stapled across its ends as well aslengthwise, close to the cable, as depicted in `C`; then it is cutlengthwise so as to free it from the cable, as shown in `D`. Analternative procedure, which is shorter but somewhat less clean, isillustrated in `Ca`; here the extirpated segment is simply cutlengthwise and folded away. In any case, the segment can be removedintact (e.g. in a bag) or after shredding. Subsequent operation is asdescribed for previous procedures.

Yet another procedure utilizing a flexible stapler and suitable forcases where the affected segment is relatively clear is illustratedschematically in FIG. 15--again, by way of an example of excision in thecolon. The stapler utilized in this procedure uses two features of theconfigurations described hereabove, namely (a) detachability andattachability of the head from, and to, the cable and (b) a clearpassageway through the cable. In addition, head 11 is equipped with ashort piece of guide wire 150, whose end is attached to the inside ofend cap 25 and which is normally disposed within the passageway in endsegment 22 of cable 21. According to this procedure, which featuresultimate cleanliness, the jaws are first inserted and positioned tostraddle the segment to be excised in a manner similar to that describedhereabove with respect to FIG. 14. Now, however, a pair of closelyspaced sutures is made across the colon at each end of the affectedsegment, as shown in `A`; it is again noted that the method of linearstapling is particularly convenient for carrying out these sutures. Thenthe colon is cut across between each pair of the sutures just made, asdepicted in `B`; it is noted that the three segments thus separatedremain totally closed, thus preventing any soilage. Next, the cable isdetached from the head and partially withdrawn, as shown in `C`; thenthe bottom and middle segments are pulled away from the upper segment,to reach the situation depicted in `D`. Now the middle, excised segmentis removed, as shown in `E`. Next, cable 21 is extended toward the headwhile end segment 22 is guided to slide around protruding guide wire150, as illustrated in `F`; it is then pushed through the suture at theend of the upper segment and into head 11, where it is again locked onto it, as shown in `G`. Subsequent operation is then as described forprevious procedures.

It is appreciated that the procedures described above are by way ofexamples only and that many variations and extensions are possible andthat they can be applied also to organs other than the colon. These maybe any of a number of hollow organs, including any part of the digestivetube (or alimentary tract) and organs external thereto, such as the gallbladder and the biliary tree, the urinary bladder and tree or thebronchial tree. The procedures may also be applied to joining twodifferent ones of such organs, as well as to joining two differentsegments of the same organ. Furthermore, neither of the parts to bejoined need to be naturally tubular near the joint (like the cut end ofthe intestines), but may, for example, be a wall of the respectiveorgan. What is common to all cases is that there is conceptuallydefined, for each of the two parts, a plane and an annular area thereon,the two annular areas being essentially congruent; during the joiningoperation, the two annular areas are brought together and conceptuallycombined into one annular area, over which the stapling and eventuallythe anastomosis take place. In the case that one of the parts is tubularat the joint, as in an end-to-end or end-to-side anastomosis, (in whichcase that part is always cut across) the defined plane is transverse anda short distance away from the plane of cutting; in the case that one ofthe parts presents an outer face of a wall at the joint, as in aside-to-end or side-to-side anastomosis, the plane is essentially atthat face. Furthermore, in the case of a tubular part, there is aninherent opening through it at the defined plane and interior to theannular area (which opening is, in some procedures, not always initiallyaccessible to the stapler, or, in some other procedures, may beintentionally closed off before the stapler reaches it); on the otherhand, in the case of a part being joined at its wall, there is no suchinitial opening and, if required by a particular procedure (e.g. forinsertion of part of the stapler thereto), a suitable opening has to becut through the wall, interior to the annular area. Of course and as theraison d'etre, after the end of the procedure there remains in all casesa clear opening through both parts.

It is further appreciated that the stapler can also be inserted throughopenings other than the anus, including, in particular, the mouth andartificial openings through the body wall, such as practiced in closedsurgery, and obviously also the wide opening of open surgery; clearly,insertion through such an artificial opening also requires a suitablelateral cut in the affected organ, for insertion of the stapler, or of ajaw, therein.

It is further appreciated that the pointed end of the cable can piercethe wall of an organ, or an artificially closed butt thereof, so as toprotrude into, or out of, the organ.

Insertion of the stapler through the body wall may be called for duringclosed surgery in cases where the affected area is too far from anatural opening, such as proximal portions of the small intestines, orwhere there are intervening obstructions or where none of the organs tobe joined has a clear passageway to a natural opening. In such cases itmay be possible to insert the stapler, including the head and/or theanvil, through a sufficiently wide trocar. Such a wide trocar would,however, be generally considered inappropriate or disadvantageous.Fortunately, configurations with detachable head and anvil, particularlythe snap-coupling configurations for attachment of the head and theanvil, described hereabove, enable alternative procedures, exemplifiedby the following, as illustrated in FIG. 16: Initially, the head isdetached from the cable and the anvil is detached from the body. A smallincision is made in the abdominal wall, through which the anvil and thehead are pushed in (dwg. A). The body of the stapler, with the cablemaximally retracted, is inserted through a trocar provided and installedfor the purpose (dwg. B); a trocar having a nominal diameter of about 10mm may be suitable. The anvil is then attached to the end of thestapler's body and the head is attached to the end of the cable (dwg.C); it is noted that the snap-coupling feature described hereabove isparticularly advantageous for these operations. The affected segment ofthe colon is excised or otherwise prepared, using laparoscopictechniques. A lateral cut is then made in the colon (dwg D), and the twojaws at the end of the stapler are inserted therethrough and pusheduntil they reach their respective butt segments (dwg. E). The butt endsare then sutured over the two jaws (dwg F) and are pulled together andstapled, as described heretofore. Finally the stapler is pulled back(dwg. G) and out through the abdominal wall, together with the trocar(dwg H). In some procedures it may be preferable to first insert the endof the body into the colon, through a small lateral cut, so that thebody protrudes into the colon, then insert the anvil, through an openend of the segment or through another lateral cut, and attach it to thebody, finally attaching also the head. It is appreciated that manyvariations of the procedures are possible--either analogous toprocedures previously described or others.

What I claim is:
 1. A flexible annular surgical stapler for staplingtogether two parts of hollow organs, the stapler comprising(a) anelongated flexible tubular body having two ends; (b) a handle attachedto a first end of said body; (c) a first jaw having an axial jaw holetherethrough and two faces, a first of said faces being attached to thesecond end of said body; (c) a flexible cable slidably disposed insidesaid body and through said jaw hole, said cable consisting of twoportions, a first of said portions defining an end segment, at leastpart of which protrudes from the second of said faces of said first jaw;and (d) a second jaw, forming a head, being attachable to said endsegment; said jaw hole having a non-circular cross-sectional shape andsaid end segment having a complementary cross-sectional shape such as toallow easy sliding of said end segment through said hole while keepingtheir mutual angular orientation about the axis of said hole fixed;wherein one of said first and second jaws includes a hammer and theother of said first and second jaws includes an anvil.
 2. The stapler ofclaim 1, wherein said head has an axial head hole, said head hole havinga cross-sectional shape such as to accomodate said end segment, whilekeeping the mutual angular orientation of said head and said end segmentabout the axis of said end segment essentially fixed.
 3. The stapler ofclaim 1, wherein said end segment is stiffer than the second one of saidtwo portions of said cable.
 4. The stapler of claim 3, wherein said endsegment is an extension rod, which is formed separately from said secondportion of said cable and which is attached thereto.
 5. The stapler ofclaim 1, wherein said handle includes(i) a housing attached to thesecond end of said body, (ii) an elongated externally threaded memberdisposed inside said housing and attached to the second portion of saidcable, (iii) a turning assembly, which includes an internally threadedmember that engages said externally threaded member, and a knob outsidesaid housing, and (iv) a lever assembly, which includes a manuallypressable lever; said turning assembly being operative, upon turning ofthe knob, to cause said cable to slide along said body, and said leverassembly being operative to keep said turning assembly at a fixed axialposition relative to said housing, when said lever is not being pressed,and to pull said turning assembly axially away from said body, when saidlever is being pressed.
 6. The stapler of claim 1, wherein said head isattachable to said end segment by a snap coupling.
 7. The stapler ofclaim 6, wherein said head further includes means for detaching saidhead from said end segment.
 8. The stapler of claim 7, wherein saidmeans for detaching can be activated electrically.
 9. The stapler ofclaim 7, wherein said end segment has an axial end hole therethrough andfurther including a guide wire attached to said head and insertable intosaid end hole.
 10. The stapler of claim 1, wherein said head furtherincludes a translucent end cap and a light source disposed inside saidend cap.